The equitable benefit approach (EBA): a single ethical framework to guide the assessment of medical and psychosocial factors in liver transplant candidacy

Liver transplantation (LT) raises ethical issues because organ scarcity implies the need for equitable access and maximum benefit from transplantation through non-discriminatory eligibility criteria and allocation systems. Patient selection and LT prioritization criteria are mainly based on medical factors. However, psychosocial, and behavioral variables are having an increasing impact on the process of patient selection and on survival after LT. Ethical concerns regarding the inclusion of non-medical factors in the selection of LT candidates are related to their potential impact on health equity issues, discrimination, and stigma. Thus, there is a need to provide ethical guidance in the assessment of LT candidacy, considering both medical and psychosocial aspects in a single framework. The aim of this paper is to present the ethical foundations of a framework proposed by the multidisciplinary group of clinical experts in LT (CELT group) of the Italian Association for the Study of the Liver (AISF). First, the updated selection and prioritization criteria for LT based on pure medical factors are presented. Then, a specific ethical framework, called Equitable Benefit Approach (EBA), is presented to provide ethical guidance in LT candidacy and prioritization. EBA clarifies the overarching goals of LT and illustrates and ranks the principles that should guide allocation decisions in LT, distinguishing between substantive and procedural principles. It also integrates medical and psychosocial criteria into a single operational algorithm to guide the selection process, prioritization, and post LT follow-up. Finally, potential strategies for implementing this proposed approach in clinical practice are presented.